What Medicare Advantage SSBCI Means for SDoH


Senior with social worker

Recent reimbursement flexibilities allow Medicare Advantage plans to address non-clinical needs.

In 2020, 36 percent of Americans over 65 chose to enroll in a Medicare Advantage (MA) plan. That's 24 million people this year alone — and a large percentage of those are those living with multiple health challenges. While chronically ill seniors make up just 17 percent of all MA recipients, they cost 15 times the amount to treat as a senior with only a single condition.

Those stats are sobering enough on their own, but when you consider that the number of Americans who are over 65 will double within the next 40 years, controlling the cost of their care will clearly be both a priority and a challenge for payers.

Fortunately, MA plans have access to a forward-thinking solution in the form of the Special Supplemental Benefits for the Chronically Ill (SSBCI). Let's break down what this program covers, why it's potentially a game-changer for MA plans, and

What is SSBCI and why does it matter

In simplest terms, SSBCI covers specific benefits designed to improve the health and overall quality of life for chronically ill enrollees. Individual MA plans can choose the benefits themselves since The Centers for Medicare and Medicaid Services (CMS) has given them "broad discretion" to develop their SSBCI programming. And starting in the upcoming plan year, CMS will provide MA plan sponsors even more flexibility on what qualifies for SSBCI reimbursement with a particular focus on SDoH.

These SDoH-related services can range from meal preparation and delivery services to non-clinical therapies like acupuncture and massage. The focus is on addressing the non-clinical factors that can cause or exacerbate ill health in seniors to improve their well-being and preventing long-term care admissions and avoidable emergency department use.

For seniors themselves, it's both a much-needed acknowledgment of the impact of SDoH on their health and a chance to access services that can improve their overall well-being. For MA plans, it's a chance to improve members' health while also reducing healthcare expenditures.

Why 2021 should be the year MA plans address SDoH

Supplemental benefits are not new, but too few MA plans are leveraging the expanded flexibilities effectively. To date, few MA plans offer the kind of benefits that fall within the SSBCI. Pest control, the most popular supplemental benefit, is offered by just 49 percent of MA plans. Food and produce assistance is offered by only 41 percent. For MA plans, these stats represent missed opportunities to both control costs and improve outcomes.

After all, chronically ill seniors are 70 percent more likely to enroll in MA plans than those with fewer health challenges, which means controlling rising costs must be a priority.

SDoH can impact up to 80 percent of health outcomes, so providing seniors with access to food, shelter, transportation, and other social services will go a long way toward reducing costly hospitalizations and improving care. With SSBCI, CMS is giving MA plans the chance to offer reimbursable services that can address those needs directly.

Your guide to SSBCI benefits

Ready to learn how MA plans can leverage SSBCI to keep costs in line as our population ages? Download our latest resource, Addressing SDoH Using Special Supplemental Benefits for the Chronically Ill.

Download Now

Topics: social determinants of health Medicare brief

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